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|
Attributes | |
ACN | 264622 |
Time | |
Date | 199402 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ont |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff ground : preflight other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 10000 |
ASRS Report | 264622 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 210 flight time total : 5000 flight time type : 2700 |
ASRS Report | 264624 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | flight crew : rejected takeoff |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While starting takeoff roll on ont runway 26R, we got the takeoff warning horn and aborted the takeoff at a slow rate of speed. Turned off at taxiway 100. Checked condition of items that could cause the horn to go off and found flaps set to 1 vs 5 degrees. We repositioned the flaps to 5, and when cleared, made a normal takeoff. The position of the flaps was missed on the before takeoff checklist due to the crew being preoccupied with both a change in the departure clearance and a discussion about an 'air conditioning packs off' operation. In the future, anything that requires non routine discussion will be done separate from the reading of any checklist. If the reading of the checklist is interrupted, it should be repeated in its entirety. Callback conversation with reporter revealed the following information: on callback the reporter indicated that this was his first experience with a release for unpressurized revenue flight. The flight crew did not have access to the MEL, but were assured that the computer printout for their release with the aircraft in that confign was available. Reporter admits to not checking that availability upon reaching the destination airport. There was only contract maintenance at the departure airport and all the release coordination from maintenance and dispatch had to be done by phone. Reporter stated that the route picked by dispatch did take into consideration the fact that they were to fly at 10000 ft. This information reference the unpressurized flight was passed onto all of the passenger and no one objected. The callback was prompted by the uniqueness of this event and as to whether the reporter had access to MEL information unavailable to the analyst. He didn't. Reporter felt that this was a primary distraction to both he and his first officer and stated that the air carrier policy does indicate a restart of the checklist if interrupted. Supplemental information from acn 264624: aircraft had multiple deferred maintenance items, including a generator inoperative and both air conditioning system inoperative. Flight was to be an unpressurized flight, which is, of course, an irregular operation for us. I was busy positioning all switches for this unusual operation and was distracted when positioning the flaps and placed them to '1' instead of '5.' flaps 1 is a normal takeoff flap position for most of our 737 fleet, yet this airplane was not yet modified for the takeoff with flaps 1. Our distrs with the deferred items on taxi-out apparently affected our performance using the checklist.
Original NASA ASRS Text
Title: TKOF ABORTED WHEN FLAPS IMPROPERLY SET FOR TKOF.
Narrative: WHILE STARTING TKOF ROLL ON ONT RWY 26R, WE GOT THE TKOF WARNING HORN AND ABORTED THE TKOF AT A SLOW RATE OF SPD. TURNED OFF AT TXWY 100. CHKED CONDITION OF ITEMS THAT COULD CAUSE THE HORN TO GO OFF AND FOUND FLAPS SET TO 1 VS 5 DEGS. WE REPOSITIONED THE FLAPS TO 5, AND WHEN CLRED, MADE A NORMAL TKOF. THE POS OF THE FLAPS WAS MISSED ON THE BEFORE TKOF CHKLIST DUE TO THE CREW BEING PREOCCUPIED WITH BOTH A CHANGE IN THE DEP CLRNC AND A DISCUSSION ABOUT AN 'AIR CONDITIONING PACKS OFF' OP. IN THE FUTURE, ANYTHING THAT REQUIRES NON ROUTINE DISCUSSION WILL BE DONE SEPARATE FROM THE READING OF ANY CHKLIST. IF THE READING OF THE CHKLIST IS INTERRUPTED, IT SHOULD BE REPEATED IN ITS ENTIRETY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: ON CALLBACK THE RPTR INDICATED THAT THIS WAS HIS FIRST EXPERIENCE WITH A RELEASE FOR UNPRESSURIZED REVENUE FLT. THE FLC DID NOT HAVE ACCESS TO THE MEL, BUT WERE ASSURED THAT THE COMPUTER PRINTOUT FOR THEIR RELEASE WITH THE ACFT IN THAT CONFIGN WAS AVAILABLE. RPTR ADMITS TO NOT CHKING THAT AVAILABILITY UPON REACHING THE DEST ARPT. THERE WAS ONLY CONTRACT MAINT AT THE DEP ARPT AND ALL THE RELEASE COORD FROM MAINT AND DISPATCH HAD TO BE DONE BY PHONE. RPTR STATED THAT THE RTE PICKED BY DISPATCH DID TAKE INTO CONSIDERATION THE FACT THAT THEY WERE TO FLY AT 10000 FT. THIS INFO REF THE UNPRESSURIZED FLT WAS PASSED ONTO ALL OF THE PAX AND NO ONE OBJECTED. THE CALLBACK WAS PROMPTED BY THE UNIQUENESS OF THIS EVENT AND AS TO WHETHER THE RPTR HAD ACCESS TO MEL INFO UNAVAILABLE TO THE ANALYST. HE DIDN'T. RPTR FELT THAT THIS WAS A PRIMARY DISTR TO BOTH HE AND HIS FO AND STATED THAT THE ACR POLICY DOES INDICATE A RESTART OF THE CHKLIST IF INTERRUPTED. SUPPLEMENTAL INFO FROM ACN 264624: ACFT HAD MULTIPLE DEFERRED MAINT ITEMS, INCLUDING A GENERATOR INOP AND BOTH AIR CONDITIONING SYS INOP. FLT WAS TO BE AN UNPRESSURIZED FLT, WHICH IS, OF COURSE, AN IRREGULAR OP FOR US. I WAS BUSY POSITIONING ALL SWITCHES FOR THIS UNUSUAL OP AND WAS DISTRACTED WHEN POSITIONING THE FLAPS AND PLACED THEM TO '1' INSTEAD OF '5.' FLAPS 1 IS A NORMAL TKOF FLAP POS FOR MOST OF OUR 737 FLEET, YET THIS AIRPLANE WAS NOT YET MODIFIED FOR THE TKOF WITH FLAPS 1. OUR DISTRS WITH THE DEFERRED ITEMS ON TAXI-OUT APPARENTLY AFFECTED OUR PERFORMANCE USING THE CHKLIST.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.